Department of Health

NHS Learning Culture

Mr Jeremy Hunt: I would like to inform the House of the steps the Government is taking to make the NHS the safest healthcare system in the world. Perhaps the single most important thing we can do is to create a learning rather than a blame culture, so that clinicians feel supported to speak out when things go wrong. NHS Improvement is today publishing a Learning from Mistakes League. This draws on data from the staff survey and safety reporting data to set out a league table for NHS provider organisations. This will provide information to the providers themselves as well as to the wider public about how well different organisations are learning, and how open and honest they are. The information in the League will be published on an annual basis as part of the CQC’s report on hospital care quality. Later this month, the NHS Improvement will also publish estimates by Trust of avoidable mortality, and information relating to this will then be published as part of an annual CQC report on care quality in hospitals. In addition to greater and more intelligent transparency, a culture of learning means we need to create an environment in which clinicians feel able to speak up about mistakes. We will therefore bring forward measures for those who speak honestly to investigators from the Healthcare Safety Investigation Branch to have the kind of ‘safe space’ that applies to those speaking to the Air Accident Investigation Branch. The General Medical Council and the Nursing and Midwifery Council have made it clear through their guidance that where doctors, nurses or midwives admit what has gone wrong and apologise, the professional tribunal should give them credit for that, just as failing to do so is likely to incur a serious sanction. The government remains committed to legal reform that would allow professional regulators more flexibility to resolve cases without stressful tribunals. NHS Improvement will ask for the commitment to learning to be reflected in all Trust disciplinary procedures and ask all Trusts to publish a Charter for Openness and Transparency so staff can have clear expectations of how they will be treated if they witness clinical errors. From April 2018, the Government will introduce the system of medical examiners recommended in the Francis Report. This will bring a profound change in our ability to learn from unexpected or avoidable deaths, with every death either investigated by a coroner or scrutinised by a second independent doctor. Grieving relatives will be at the heart of the process and will have the chance to flag any concerns about the quality of care and cause of death with the independent clinician. NHS England is working with the Royal College of Physicians to develop and roll-out across the NHS a standardised method for reviewing the records of patients who have died in hospital. These measures, along with the professionalism and dedication of NHS staff will help the NHS to achieve its aim of becoming the world’s largest learning organisation.


This statement has also been made in the House of Lords: 
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